L'absence de traitement médical assurant avec certitude l'arrêt des destructions articulaires de la polyarthrite rhumatoïde (PR) laisse une grande place au traitement chirurgical. Le but de notre travail était de savoir si, malgré l'aggravation des lésions radiologiques, il persiste à très long terme (supérieur à 20 ans) un bénéfice clinique après chirurgie du poignet rhumatoïde.

Seize patients (13 femmes et 3 hommes) d'âge moyen 65 ans, atteints de PR ont été revus avec un recul moyen de 24,8 ans (entre 20 et 33 ans) après intervention sur le poignet. Vingt-quatre poignets avaient été opérés. Dix-huit avaient bénéficié d'une synovectomie dorsale, 6 d'un implant radio-carpien de Swanson. Lors de la révision, nous avons réalisé un bilan clinique, fonctionnel, radiologique standard et dynamique.

À la revue, les poignets opérés par synovectomies dorsales présentaient une douleur résiduelle à 3,1/10 sur l'échelle EVA contre 5,6 en préopératoire. Trois quarts des patients étaient satisfaits de l'intervention, malgré une force très faible. L'état radiologique s'aggravait avec le temps.

Après implant de Swanson, la douleur résiduelle n'était plus que de 0,5/10 contre 6,7 en préopératoire. Quatre implants étaient fracturés et 4 présentaient des signes radiologiques de siliconite sans signe clinique. Malgré ces complications, 5 patients sur 6 jugaient favorablement leur intervention et le score fonctionnel moyen était à 78/100.

Il existe une discordance radio-clinique d'autant plus flagrante que le recul est important. L'amélioration franche de la douleur et les faibles besoins fonctionnels font que ces patients sont satisfaits malgré la constante dégradation radiologique.

The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist.

Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n = 18) and Swanson radiocarpal implant (n = 6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up.

Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56° on average. The main complaint was the lack of force.

There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.